Adolescent Medicine

When I tell my fellow historians that I have published a book on the history of adolescent medicine, the usual response is "What is adolescent medicine?" I hear the same thing from many other people. It seems the world is largely unaware of the existence of a medical specialty dedicated to the unique developmental needs of teenagers, even though the field was established nearly half a century ago, and has been growing rapidly ever since.

This lack of awareness is matched by a lack of understanding of the serious shortage of age-appropriate health services for American teenagers. Children Now, a national
nonprofit child policy organization based in Oakland, California, recently spotlighted
some of the issues in a report entitled Partners in Transition: Adolescents and Managed Care. For example, 20 percent of teenagers surveyed said they had gone
without medical treatment they thought they needed. Their reasons included the absence of appropriate services in their community, lack of transportation to medical facilities, and fear their parents would be notified if they sought medical care.

Why this shortage? In my book, A Doctor of Their Own, I argue that the fate of adolescent medicine as a medical field is closely connected to broader societal views about adolescents. Although many adults in our society, especially aging baby-boomers, try to look youthful for as long as possible, they tend to view actual young people with suspicion. This negative view of teenagers is reinforced by the kinds of adolescent health issues that seem to receive the most media attention, e.g. teen violence, pregnancy, and substance abuse. Media descriptions often blame these problems on "bad" teenagers, rather than on larger societal problems. As a result, adolescent health issues are not considered a priority by many adults, particularly those who make decisions about allocating health care dollars.

Reflections on Adolescent Medicine and Teen Health

Before I started exploring the history of adolescent medicine, I didn't know the specialty existed either. When I was a teenager in the 1970s, there was no adolescent clinic in the area. By the time I was sixteen, I considered myself too old for the pediatrician. But I was mortified when my mother took me to her internist, remaining in the room during the entire exam. Even if there had been an adolescent clinic at my local medical center, I doubt I would have known about it, nor would I have had the resources or courage to go there on my own. I didn't learn there was a specialty called adolescent medicine until I was in graduate school, when I discovered the literature on this field while searching for a dissertation topic.

Adolescent medicine first emerged as a branch of pediatrics during the early 1950s. The first medical unit in the United States devoted exclusively to adolescents was founded by Dr. J. Roswell Gallagher at Boston Children's Hospital in 1951. The Adolescent Unit pioneered a major shift in approach to the teenage patient: prior to the 1950s, most physicians who treated adolescents discussed the patient's health problems with the parent, and seldom allowed young people to speak for themselves. In contrast, Gallagher and his staff insisted that teenage patients needed "a doctor of their own" who would see patients separately from their parents, who would protect their confidentiality, and who would place teenagers' concerns first.

The Adolescent Unit was also the first center of its kind to recognize the unique social and psychological needs of teenagers and the role that these factors play in adolescent health problems and their treatment. Gallagher and the unit's other physicians argued that teenagers with chronic illnesses, abnormalities in growth and development, disabilities, or emotional problems were likely to have low self-esteem, since these health difficulties interfered with their ability to fit in with their peers. Therefore, successful treatment of adolescent health problems required that a physician not only address the particular disease or disorder, but the psychological and social consequences as well.

The Boston Adolescent Unit served as a model for other hospitals in North America. By
the mid-1960s, there were 55 adolescent clinics in hospitals in the United States and
Canada, and today over half of all children's hospitals in the United States have units
dedicated to the health care of teenagers. The expansion of adolescent health services led to the creation of a professional organization for adolescent specialists, the Society for Adolescent Medicine (SAM), established in 1968; the founding of a professional journal, The Journal of Adolescent Health first published in 1980; and the decision in 1991 to institute a board-certification examination for
physicians interested in becoming sub-specialists in adolescent medicine.

The Society for Adolescent Medicine recognizes that most health professionals who serve adolescents are not board certified in adolescent medicine, but instead are general pediatricians, family practitioners, internists, gynecologists, or nurse practitioners. The society welcomes all health care providers who spend a substantial portion of their practice treating teenagers. In fact, some members of SAM have even suggested that the organization's name be changed to "Society for Adolescent Health Care" to reflect the fact that many of their members are not physicians.

But problems can arise when health professionals who see teenagers in their practices have not been exposed to the concepts of adolescent medicine in their training. Only half of all teaching hospitals in the country have specialists in adolescent medicine on their staff, and even those facilities that do offer training in this area frequently treat adolescent medicine as an elective rather than as an essential subject for all health care professionals. Surveys of health care providers indicate that many of them believe they are not well prepared to diagnose such critical adolescent health problems as substance abuse, sexually transmitted diseases, eating disorders, and emotional and behavioral difficulties.

The recent growth of managed care plans has been a mixed blessing for adolescent
medicine. According to Partners in Transition, some managed care facilities have created innovative adolescent health care programs that provide age-appropriate medical treatment at lower cost than traditional fee-for-service programs, and which can provide models for other health plans around the country. However, not all managed care plans offer adolescent health care. At the same time, managed care plans have drawn patients away from university teaching hospitals, which are the institutions primarily responsible for training adolescent health professionals and conducting research on adolescent health issues.

Specialists in adolescent medicine are working hard to overcome negative stereotypes about teenagers, and help convince adults that investing in adolescent health programs is worthwhile. They argue that giving teenagers age-appropriate care not only helps eliminate the most troubling adolescent health problems, such as unplanned pregnancy and substance abuse, but can also prevent adult health problems by educating young people about the importance of life-long healthy habits. Those who remember their embarrassment at being faced with the choice of going to a "baby doctor" or their parents doctor should recognize and support this unique health care specialty.